Free Braces

Second Opinion

Online SECOND OPINION

 IF YOUR CHILD HAS BEEN EXAMINED BY A FREE BRACES DOCTOR AND THE DOCTOR SAID THAT THE PROBLEMS WERE NOT SEVERE ENOUGH TO QUALIFY FOR THE INSURANCE TO PAY FOR TREATMENT .........

COMPLETE THIS ONLINE FORM TO OBTAIN A SECOND OPINION FROM OUR CONSULTANT 

  All information remains confidential and will not be used to generate spam to your email address.  Nor is any information ever sold to third parties!!  

Thank you so much for visiting our site!  

Please tell your friends and family about us!

There is a section in the online form for you to ask questions.  If you have additional questions you can Reach us at info@freebraces.net 

(Any questions about qualifying for the free braces program can only be answered by the Free Braces Doctors.  Call one of them to schedule an exam to determine if your problems meet the program requirements.)
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
How old is the patient seeking treatment?:
List the name of your dental insurance or state funded medicaid (Medi-Cal) benefits.:
Has the patient recently had a braces exam?:
If yes what did the doctor say was needed?:
Does your child have any joint pain and/or clicking?:
Name the alignment or bite problem that you feel would allow your child to qualify for the insurance to cover the treatment cost?:
Does your child have any self esteem problems because of the appearance of their smile?:
If there are any significant health problems we should be aware of list them here:
When was the last time you visited the dentist?:
What internet search website did you use to find our website?:
If you don't qualify for the Free Braces and were offered a discount plan for braces, how much could you afford per month?:
Are there any questions that we can answer for you when we contact you?:
What is the name, address, and phone number of the Free Braces doctor that examined your child so that we can contact them to appeal the decision?: